- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.77 / $232.11 / $1,253.65
| Professional | | $150.77 | $232.11 | $1,253.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.14 / $287.82 / $1,504.76
| Professional | | $178.14 | $287.82 | $1,504.76 |
- Facility/Professional
- Professional
- Modifier
- 50
- Low / Median / High Price
- $267.20 / $426.35 / $2,257.14
| Professional | 50 | $267.20 | $426.35 | $2,257.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.99 / $1,181.79 / $1,749.86
| Professional | | $182.99 | $1,181.79 | $1,749.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.08 / $426.89 / $1,723.39
| Professional | | $185.08 | $426.89 | $1,723.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.77 / $232.11 / $1,253.65
| Professional | | $150.77 | $232.11 | $1,253.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,250.76 / $1,539.39 / $1,914.89
| Professional | | $1,250.76 | $1,539.39 | $1,914.89 |